What is the recommended treatment for esophageal candidiasis?

Treatment of Esophageal Candidiasis

Oral fluconazole at a dosage of 200-400 mg (3-6 mg/kg) daily for 14-21 days is the recommended first-line treatment for esophageal candidiasis. 1, 2

First-Line Treatment Algorithm

• Initiate oral fluconazole with a loading dose of 200-400 mg on day 1, followed by 200-400 mg daily 1, 3
• Continue treatment for 14-21 days and for at least 2 weeks following resolution of symptoms 1, 2
• A diagnostic trial of antifungal therapy is appropriate before performing an endoscopic examination if symptoms are typical 1, 2
• Most patients will show clinical improvement within 48-72 hours of starting therapy 2

Alternative Options for Patients Unable to Take Oral Therapy

• Intravenous fluconazole 400 mg (6 mg/kg) daily is recommended for patients who cannot tolerate oral therapy 1, 3
• Echinocandins are effective alternatives for patients unable to take oral medications 1:
  • Micafungin 150 mg daily IV 1, 2
  • Caspofungin 70 mg loading dose, then 50 mg daily IV 1, 2
  • Anidulafungin 200 mg daily IV 1, 2, 4
• Amphotericin B deoxycholate 0.3-0.7 mg/kg daily IV is a less preferred alternative due to toxicity concerns 1, 2
• Consider de-escalating to oral fluconazole once the patient can tolerate oral intake 1

Management of Fluconazole-Refractory Disease

• For fluconazole-refractory esophageal candidiasis, the following options are recommended 1, 2:
  • Itraconazole oral solution 200 mg daily for 14-21 days 1, 5
  • Voriconazole 200 mg (3 mg/kg) twice daily orally or IV for 14-21 days 1, 2
  • Echinocandins (micafungin, caspofungin, or anidulafungin) for 14-21 days 1, 6
  • Amphotericin B deoxycholate 0.3-0.7 mg/kg daily for 21 days 1, 2
• Posaconazole suspension 400 mg twice daily or extended-release tablets 300 mg once daily can be considered, though evidence is limited 1, 2

Prevention of Recurrent Infections

• For patients with recurrent esophageal candidiasis, chronic suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 1, 2
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 1

Special Considerations

• Itraconazole oral solution should be vigorously swished in the mouth (10 mL at a time) for several seconds and swallowed 5
• Itraconazole capsules are less effective than the oral solution due to variable absorption 2
• For patients with renal impairment receiving fluconazole, dose adjustment is necessary when creatinine clearance is ≤50 mL/min (reduce dose by 50%) 3
• Echinocandins, while effective, are associated with higher relapse rates than fluconazole and are only available parenterally 2, 6
• Treatment failure is defined as persistence of symptoms after 7-14 days of appropriate therapy 2

Comparative Efficacy

• Clinical studies have demonstrated that fluconazole is superior to flucytosine for treating esophageal candidiasis, with higher endoscopic cure rates 7
• Fluconazole has similar efficacy to amphotericin B but with fewer adverse reactions 8
• Anidulafungin has been shown to be as effective as fluconazole for esophageal candidiasis (97.2% vs 98.8% endoscopic success) with a similar safety profile 4
• Micafungin at doses of 100 mg and 150 mg daily has comparable efficacy to fluconazole 200 mg daily, with endoscopic cure rates of 77.4% and 89.8% respectively 6